Section title: Requests for Interpretation
RFI #
2375
Submitted vs Adjudicated Codes
Description

We have an 835 scenario where the SVC01-02 contains a valid 4 position revenue code and the SVC06-02 contains an invalid 3 position revenue code (it is a subset of the 4 byte revenue code). Considering the information in RFI 366, should a validation tool relax the edits in SVC06-02 due to the fact that the payer is simply reporting back the invalid code that they received? Should validation tools always relax their edits in the SVC06-02, regardless of what type of code it is (HCPCS etc.) due to the potential of it being invalid?

Response

In the 835 transaction, SVC01-2 contains the adjudicated procedure code, and SVC06-2 contains the submitted procedure code (when it differs from what was adjudicated).  Even when the submitted procedure code is invalid, it should be returned in SVC06-2 to indicate what code was submitted and that it differs from what was adjudicated. Because the element now contains an invalid code (regardless of the type), this requires that all editors relax edits on SVC06-2.
As indicated in RFI 366, the Office of e-Health Standards and Services (CMS/OESS) supports this opinion.

DOCUMENT ID
005010X221A1